title: Substituted judgment in principle and practice: a national physician survey.
abstract: OBJECTIVE
  To describe the extent to which US physicians endorse substituted judgments in principle or accommodate them in practice.
  
  
  METHODS
  We surveyed a stratified, random sample of 2016 physicians by mail from June 25, 2010, to September 3, 2010. Primary outcome measures were agreement with 2 in-principle statements about substituted judgment and, after an experimental vignette that varied the basis used by a patient's surrogate to refuse life-saving treatment, responses indicating how appropriate it would be to overrule the surrogate's decision.
  
  
  RESULTS
  Our response rate was 62% (1156 of 1875 respondents). When there is a conflict between what a surrogate believes a patient would have wanted (substituted judgment) and what the surrogate believes is in the patient's best interest, 4 of 5 physicians (78%) agreed that the surrogate should base their decision on substituted judgment. Yet we also found that 2 of 5 physicians (40%) agree that surrogates should make decisions they believe are in the patient's best interest, even if those seem to contradict the patient's prior wishes. In the experimental vignette, physicians were much more likely to oppose overruling a surrogate's refusal of life-sustaining medical treatment when that refusal was made on the basis of substituted judgment compared with when the refusal was made on the basis of the patient's best interest (50% vs 20%; odds ratio, 4.2; 95% CI, 2.7-6.3). Responses to the in-principle items about substituted judgment were not consistently associated with responses to the experimental vignette.
  
  
  CONCLUSIONS
  US physicians largely agree, in principle, that surrogates should prioritize what the patient would have wanted over what they believe is in the patient's best interest, although many physicians are ambivalent in cases in which the 2 norms conflict. Even physicians who reject the principle of substituted judgment tend to treat substituted judgment as the preferred norm for surrogate decision making when responding to a clinical vignette.
authors.affiliation: Pritzker School of Medicine, The University of Chicago, Chicago, IL.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Combs
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Rasinski
authors.forename: John D
authors.initials: JD
authors.lastname: Yoon
authors.forename: Farr A
authors.initials: FA
authors.lastname: Curlin
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D005260:Female; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data; D006801:Humans; D007600:Judgment; D008297:Male; D008875:Middle Aged; D057240:Patient Preference / Q000706:statistics & numerical data*; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D018802:Patient-Centered Care / Q000379:methods; D010817:Physician-Patient Relations; D010820:Physicians / Q000706:statistics & numerical data*; D011159:Population Surveillance; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D011795:Surveys and Questionnaires; D014481:United States